What is the management approach for a patient with a retroperitoneal (behind the peritoneum) bleed after catheter (cath) treatment?

Management of Retroperitoneal Bleed Post-Catheterization

Immediately obtain CT abdomen/pelvis with IV contrast (or CTA if hemodynamically stable) to confirm diagnosis and identify active bleeding, then manage based on hemodynamic status: unstable patients unresponsive to volume resuscitation require urgent operative intervention or angioembolization, while stable patients can be managed conservatively with transfusion and serial monitoring. 1

Initial Diagnostic Approach

Imaging is the critical first step:

• CT abdomen/pelvis with IV contrast or CTA is the diagnostic modality of choice for suspected retroperitoneal bleeding after catheterization 2, 1
• CTA is superior when active bleeding is clinically suspected, as it can detect bleeding rates as slow as 0.3 mL/min and provides detailed vascular information 1
• Non-contrast CT alone is appropriate in patients with compromised renal function or when additional contrast load is a concern if subsequent angiography may be needed 2, 1
• Do not delay CT imaging in stable patients with clinical suspicion—early diagnosis (within first 5 hours) significantly improves outcomes 1
• Ultrasound is NOT appropriate for initial diagnosis due to limited acoustic windows and inability to evaluate the entire retroperitoneum reliably 1

Key clinical signs to recognize:

• Suprainguinal tenderness and fullness (present in 100% of cases) 3
• Severe back and lower quadrant pain (64% of cases) 3, 4
• Femoral neuropathy from nerve compression (36% of cases) 3, 4
• Falling hematocrit (73% of cases) 4
• Hypovolemic shock with systolic blood pressure <90 mmHg (64% of cases) 4

Management Algorithm Based on Hemodynamic Status

Hemodynamically Unstable Patients

Urgent intervention is required for:

• Hypotension unresponsive to volume resuscitation 1, 3
• Pulsatile or expanding retroperitoneal hematoma discovered during laparotomy 1
• Uncontrollable life-threatening hemorrhage 1

Two intervention options exist:

1. Urgent operative intervention for patients who develop hypotension unresponsive to volume resuscitation early after catheterization 3, 4
2. Urgent aortography with transcatheter arterial embolization (TAE) for patients with high index of clinical suspicion and known active arterial bleeding 2

Hemodynamically Stable or Stabilized Patients

Conservative management is successful in most cases (79-84% of patients): 3, 5

• Transfusion support as the primary treatment modality 3, 5
• Stop or minimize anticoagulation immediately 4
• Serial hematocrit monitoring 4
• Serial CT imaging to evaluate for rebleeding or hematoma progression 1, 4

Super-selective angioembolization is indicated for stable patients with: 1

• Arterial contrast extravasation on CT 1
• Pseudoaneurysms 1
• Arteriovenous fistula 1
• Angioembolization achieves cessation of bleeding in nearly 100% of cases when active bleeding is identified on angiography 2, 1
• Perform embolization as selectively as possible to preserve organ function 1

Critical caveat: Blind angioembolization is NOT indicated in stable patients with negative angiography, regardless of arterial contrast extravasation on CT scan 1

Delayed Surgical Intervention

Operative intervention may be required 24-72 hours after catheterization for: 3

• Progressive fall in hematocrit level despite transfusion 3
• Hematoma progression documented by serial CT 4
• Femoral nerve palsy requiring urgent decompression (complete resolution occurs in 67% of cases with early decompression) 4

Special Considerations and Risk Factors

High-risk features associated with retroperitoneal bleeding post-catheterization:

• Female sex 3, 5
• Younger age 5
• Excessive anticoagulation or dual antiplatelet therapy 3, 5
• Coronary artery stenting (3% incidence vs 0.5% overall) 3
• High arterial puncture site 4
• Use of glycoprotein IIb-IIIa inhibitors (20.8% of cases) 5

Timing considerations:

• Median time to diagnosis is 9 hours after catheterization 5
• Onset of bleeding can be delayed in patients with vascular closure devices (median 12 hours vs 5 hours without devices) 5
• Maintain high clinical suspicion for delayed presentation up to 72 hours post-procedure 3, 5

Monitoring and Follow-up

Follow-up CT is appropriate to evaluate for: 1

• Rebleeding or changes in hematoma size 1
• Complications such as infection and abscess formation 1
• CT findings help determine acuity: high attenuation indicates acute bleeding, mixed attenuation suggests rebleeding, and low attenuation indicates subacute to chronic blood products 1

Mortality and Outcomes

• Overall mortality ranges from 4.2% to 18% when retroperitoneal hematoma occurs post-catheterization 3, 5, 4
• Most deaths occur in patients with delayed recognition or inadequate volume resuscitation 4
• Mean transfusion requirement is approximately 8.7 units in patients requiring operative intervention 4